Form 5091 - Request For Motor Vehicle/driver License Records/personal Information

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MISSOURI DEPARTMENT OF REVENUE

FORM

MOTOR VEHICLE AND DRIVER LICENSING DIVISION — RECORD CENTER

PO BOX 2167, JEFFERSON CITY MO 65105-2167

5091

(573) 526-3669

FAX: (573) 526-7367

REQUEST FOR MOTOR VEHICLE/DRIVER LICENSE RECORDS/PERSONAL INFORMATION

(REV. 05-2013)

INSTRUCTIONS: THIS APPLICATION MUST BE COMPLETED AND APPROVED BEFORE AN APPLICANT CAN OBTAIN RESTRICTED INFORMATION.

ONLY APPLICANTS WHO MEET THE CRITERIA OUTLINED IN SECTION B ARE ELIGIBLE TO OBTAIN RESTRICTED INFORMATION.

SECTION A. REQUESTER INFORMATION (THIS SECTION MUST BE COMPLETED BY ALL.)

NAME OF INDIVIDUAL OR ORGANIZATION

TELEPHONE NUMBER

FAX NUMBER

(

)

(

)

REQUESTER NAME

Check

Individual

Partnership

News Media

one:

Corporation

Government Agent

LLC

ADDRESS

CITY

STATE

ZIP CODE

MAILING ADDRESS (IF DIFFERENT)

CITY

STATE

ZIP CODE

DESCRIBE THE PRIMARY FUNCTION OF YOUR BUSINESS

E-MAIL

DESCRIBE HOW THE INFORMATION WILL BE USED

SECTION B. AUTHORIZATION (THIS SECTION MUST BE COMPLETED BY ALL.)

Requester hereby certifies to the Missouri Department of Revenue (Department) that this request for Missouri motor vehicle and/or driver license records or

information is made under the provisions of the Federal Driver’s Privacy Protection Act (DPPA) and Missouri law. Please review and carefully check all

boxes that apply to requester to obtain personal information on a restricted record. Requester is seeking information:

(01) As a government agency (federal, state, or local) or on behalf of a government agency, in carrying out its government functions.

(02) As a court (federal, state, or local) or on behalf of a court, in carrying out its court functions.

(03) As a law enforcement agency (federal, state, or local) or on behalf of a law enforcement agency, in carrying out its law enforcement functions.

(04) For use in connection with matters of motor vehicle or driver safety and theft; motor vehicle emissions, motor vehicle product alterations, recalls, or

advisories; performance monitoring of motor vehicles, motor vehicle parts and dealers; motor vehicle market research activities, including survey

research; and removal of non-owner records from the original owner records of motor vehicle manufacturers.

(05) For use as a legitimate business only (a) to verify the accuracy of personal information submitted by an individual to the business or its agents,

employees, or contractors and (b) if such information is not correct, to obtain the correct information, but only for the purposes of preventing fraud by

pursuing legal remedies, or recovering on a debt or security interest, against the individual. (For individual requests only.)

(06) For use in connection with any civil, criminal, administrative, or arbitral proceeding in any federal, state, or local court or agency or before any

self-regulatory body, including the service of process, investigation in anticipation of litigation, and the execution or enforcement of judgments and orders,

or pursuant to an order of a federal, state, or local court.

(07) For use in research activities, and producing statistical reports, so long as the personal information is not published, redisclosed, or used to contact

individuals.

(08) As an insurer, insurance support organization, or self-insured entity for use in connection with claims investigation activities, antifraud activities, rating

or underwriting.

(09) For use in providing notice to the owners of towed or impounded vehicles.

(10) For use by a licensed private investigative agency or licensed security service for a purpose permitted herein.

(11) For use as an employer, its agent or insurer in obtaining or verifying motor vehicle/driver record information relating to a holder of a commercial

driver’s license (CDL).

(12) For use in the operation of a private toll transportation facility.

(13) To disseminate to the public in a newspaper, book, magazine, broadcast, or similar form of public communication, when such dissemination is

related to the operation of a motor vehicle or to public safety.

Requester certifies under penalty of perjury that: 1) all information on this application has been read and understood; 2) all information completed on this

application is true and correct; and 3) the willful and unauthorized disclosure of information obtained from any Department record may result in penalties

imposed under Title 18 U.S.C. Section 2724.

Requester understands that Section 302.183.2, RSMo, prohibits the sale of data derived from a person’s driver’s license application for commercial

purposes, which includes purposes motivated primarily by financial gain such as, but not limited to, surveys, marketing or solicitations, without the express

consent of the person to whom such information pertains. Requester shall not sell personal information for commercial purposes without such consent.

SIGNATURE(S) OF INDIVIDUAL, PARTNERS (ALL REQUIRED), AUTHORIZED MEMBER OR CORPORATE OFFICER, NEWS AGENT, OR GOVERNMENT AGENT

PRINTED NAME(S)

TITLE OF CORPORATE OFFICER, NEWS AGENT, OR GOVERNMENT AGENT

NOTARY INFORMATION

STATE

COUNTY (OR CITY OF ST. LOUIS)

NOTARY PUBLIC EMBOSSER OR

BLACK RUBBER STAMP SEAL

SUBSCRIBED AND SWORN BEFORE ME, THIS

DAY OF

YEAR